New test measures doctors' ability to deliver patient-centered care

When health care providers take patients' perspectives into consideration, patients are more likely to be actively engaged in their treatment and more satisfied with their care. This is called patient-centered care, and it has been the central focus of the curriculum at the University of Missouri School of Medicine since 2005. Recently, MU researchers have developed a credible tool to assess whether medical students have learned and are applying specific behaviors that characterize patient-centered care.

The researchers first worked with real patients to identify a list of specific behaviors that demonstrated physicians were providing patient-centered care. By defining these detailed, specific patient-centered behaviors, the researchers have been able to tailor the educational experience at the MU School of Medicine to help students gain these skills.

MU medical students now are assessed on their ability to deliver the care in ways the patients expect; students must perform at a satisfactory level on the patient-centered care exam to graduate from the MU School of Medicine.

"The test forces the future physician to go beyond just determining a diagnosis and to focus on behaviors that play an essential role to the effectiveness of the care he or she provides," said Kimberly Hoffman, Ph.D, associate dean for curriculum and assessment, and research associate professor of family and community medicine at MU.

Hoffman is the author of a study describing how the assessment tool for patient-centered care was developed at the MU School of Medicine. In the article, Hoffman also outlines a process for having patients validate the assessment.

The test of patient-centered care behaviors is given to third-year medical students. The exam is given in the third year because it is then the students are immersed in their clinical rotations. Before the third year of medical school, most of the studies are done in a classroom, lab or simulation-center setting. The test is called the Patient-centered Care - Objective Structured Clinical Exam (PCC-OSCE).

"We developed very real, complex scenarios," said Hoffman. "The test uses standardized patients, standardized family members and standardized health providers to simulate real-life situations."

The standardized patient (an actor) is trained to take on characteristics of a real patient and portray the roles of patients, family and others. Students are tested on how they interact with standardized patients ranging from adolescents to senior citizens, how to solicit information from the patient, and how to create a management and care plan that reflects the patient's preferences.

"One thing that is pretty striking with our curriculum is how early you get involved in patient care, with an emphasis on patient-centered care," said Woody Smelser, a fourth-year medical student from New Madrid, Missouri, who is president of his medical school class at MU. We get immersed in it early on. A good example is in the second week of medical school, you start to see your first patient in the simulation center. From that moment, the medical students are assessed on things like building rapport, making good eye contact, intently listening to the patients' concerns, and finding out the real reason for the visit, which may not be what is actually listed on the sheet the doctors are given."

"The test takes all the skills you have learned in the first three years of medical school and combines them with elements of patient-centered care," said Smelser. It assesses in many different ways if the medical student is able to make the transition from a student to a practicing physician."

From this authentic assessment, researchers learned students were picking up on many key factors in patient-centered care. Most MU medical students had strong, effective communication skills, didn't use medical jargon, actively listened to the patient, showed empathy and were in charge of the situation when they needed to lead a critical conversation.

"We get very detailed feedback, in the form of comments, and even videos, from our simulation-center encounters and through the patient-centered care exam," said Smelser. "When we can actually see things we did and did not do—like crossing our arms, making us appear guarded and not open to the patient—it helps us to overcome some of those behaviors we may not have realized we were using, and it reinforces the good behaviors we did do."

"MU Health Care shares our focus on putting patients first, and that helps us reinforce the importance of this to learners," said Hoffman.

"By the time we take the exam in our third year, we are all confident we have the skill set or developed this skill over the course of the last two to three years," said Joshua Geltman, a third-year medical student from St. Louis, who is also president of his medical school class. Patient-centered care is our default, it's our baseline; that's the way we have learned how to become a physician. Now it is just the norm, not a separate skill set because it is included in every aspect of what we have learned in medical school."

Geltman has not yet taken the patient-centered care exam yet, but says the curriculum has positioned him up for success.

"Putting a grade and critique on our ability is a needed task," Geltman said. "It will enable the School of Medicine to produce even better physicians not just in measure of performance but the quality of care they are able to deliver to their patients."

Through these tests, School of Medicine faculty members have also been able to identify other opportunities where students can improve. Many of those include examining barriers a patient could face that would cause problems with compliance with the treatment plan and routinely involving family members and other members of the health care team in the patient's care.

Hoffman said the use of the assessment has had another positive outcome - School of Medicine faculty members have begun volunteering to grade the patient-centered care exams.

"It is prompting reflection among our faculty on their own medical practices, and how they may continually improve their own patient-centered care behaviors," she said.

Hoffman's research was published in September in Medical Teacher, an international journal of education in the health sciences.

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